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European Radiology

, Volume 29, Issue 2, pp 663–673 | Cite as

Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management

  • Sarah Fadili Hassani
  • Evelyne Cormier
  • Eimad Shotar
  • Mehdi Drir
  • Jean-Philippe Spano
  • Laetitia Morardet
  • Jean-Philippe Collet
  • Jacques Chiras
  • Frédéric ClarençonEmail author
Interventional
First Online:
  • 183 Downloads

Abstract

Objective

To evaluate the incidence and risk factors for ICE during a PV.

Materials and methods

Single-center retrospective analysis of 1512 consecutive patients who underwent 1854 PV procedures for osteoporotic (34 %), malignant (39.9 %) or other cause (26.1 %) of vertebral compression fractures (VCFs)/spine tumor lesions. Only thoracic or lumbar PVs were included. PVs were performed with polymethylmethacrylate (PMMA) low-viscosity bone cement under fluoroscopic guidance. Chest imaging (X-ray or CT) was performed the same day after PV in patients with high clinical suspicion of ICE. All post-procedural chest-imaging examinations were reviewed, and all ICEs were agreed upon in consensus by two radiologists.

Results

ICEs were detected in 72 patients (92 cement embolisms). In 86.1 % of the cases, concomitant pulmonary artery cement leakage was detected. Symptomatic ICEs were observed in six cases (8.3% of all ICEs; 0.32% of all PV procedures). No ICE led to death or permanent sequelae. Multiple levels treated during the same PV session were associated with a higher ICE rate [OR: 3.59, 95% CI: (1.98-6.51); p < 0.001]; the use of flat panel technology with a lower ICE occurrence [OR: 0.51, 95% CI: (0.32-0.83); p = 0.007].

Conclusion

Intracardiac cement embolism after PV has a low incidence (3.9 % in our study). Symptomatic complications related to ICE are rare (0.3%); none was responsible for clinical sequelae in our series.

Key Points

• The incidence of intracardiac cement embolism (ICE) during PVP is low (3.9%).

• Having a high number of treated vertebrae during the same session is a significant risk factor for ICE.

• Symptomatic intracardiac cement embolisms have a low incidence (8.3% of patients with ICE).

Keywords

Percutaneous vertebroplasty Leakage Cement Embolism Cardiac Complication 

Abbreviations

AP

Anteroposterior

ICE

Intracardiac cement embolism

IV

Intravenous

PCE

Pulmonary cement embolism

PMMA

Polymethylmethacrylate

PV

Percutaneous vertebroplasty

RA

Right atrium

RAA

Right atrial appendage

RV

Right ventricle

VCF

Vertebral compression fracture

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Notes

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Prof. Frédéric Clarençon.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was not required because French law states that no approval from a local IRB is necessary for retrospective analysis of patients' charts.

Methodology

• retrospective

• observational

• performed at one institution

References

  1. 1.
    Calmels V, Vallée J-N, Rose M, Chiras J (2007) Osteoblastic and mixed spinal metastases: evaluation of the analgesic efficacy of percutaneous vertebroplasty. AJNR Am J Neuroradiol 28:570–574Google Scholar
  2. 2.
    Anselmetti GC, Marcia S, Saba L et al (2012) Percutaneous vertebroplasty: multi-centric results from EVEREST experience in large cohort of patients. Eur J Radiol 81:4083–4086.  https://doi.org/10.1016/j.ejrad.2012.07.005 CrossRefGoogle Scholar
  3. 3.
    Clarençon F, Fahed R, Gabrieli J et al (2016) Safety and clinical effectiveness of percutaneous vertebroplasty in the elderly (≥80 years). Eur Radiol 26:2352–2358.  https://doi.org/10.1007/s00330-015-4035-2 CrossRefGoogle Scholar
  4. 4.
    Barragán-Campos HM, Vallée J-N, Lo D et al (2006) Percutaneous vertebroplasty for spinal metastases: complications. Radiology 238:354–362.  https://doi.org/10.1148/radiol.2381040841 CrossRefGoogle Scholar
  5. 5.
    Masala S, Mastrangeli R, Petrella MC et al (2009) Percutaneous vertebroplasty in 1,253 levels: results and long-term effectiveness in a single centre. Eur Radiol 19:165–171.  https://doi.org/10.1007/s00330-008-1133-4 CrossRefGoogle Scholar
  6. 6.
    Mathis JM (2003) Percutaneous vertebroplasty: complication avoidance and technique optimization. AJNR Am J Neuroradiol 24:1697–1706Google Scholar
  7. 7.
    Chen Y-J, Tan T-S, Chen W-H et al (2006) Intradural cement leakage: a devastatingly rare complication of vertebroplasty. Spine 31:E379–E382.  https://doi.org/10.1097/01.brs.0000219495.57470.67 CrossRefGoogle Scholar
  8. 8.
    Gaye M, Fuentes S, Pech-Gourg G et al (2008) Spondylodiscite post-vertébroplastie. Cas clinique et revue de la littérature. Neurochirurgie 54:551–555.  https://doi.org/10.1016/j.neuchi.2008.02.063 CrossRefGoogle Scholar
  9. 9.
    Laredo JD, Hamze B (2004) Complications of percutaneous vertebroplasty and their prevention. Skeletal Radiol 33. doi:  https://doi.org/10.1007/s00256-004-0776-8
  10. 10.
    Groen RJM, du Toit DF, Phillips FM et al (2004) Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system. Spine (Phila Pa 1976) 29:1465–1471Google Scholar
  11. 11.
    Schmidt R, Cakir B, Mattes T et al (2005) Cement leakage during vertebroplasty: an underestimated problem? Eur Spine J 14:466–473.  https://doi.org/10.1007/s00586-004-0839-5 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Geraci G, Lo Iacono G, Lo Nigro C, Cannizzaro F, Cajozzo M, Modica G (2013) Asymptomatic bone cement pulmonary embolism after vertebroplasty: case report and literature review. Case Rep Surg 2013, 2013:591432.  https://doi.org/10.1155/2013/591432
  13. 13.
    Venmans A, Klazen CAH, Lohle PNM et al (2010) Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. AJNR Am J Neuroradiol 31:1451–1453.  https://doi.org/10.3174/ajnr.A2127 CrossRefGoogle Scholar
  14. 14.
    Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF (2011) Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol 32:654–657.  https://doi.org/10.3174/ajnr.A2368 CrossRefGoogle Scholar
  15. 15.
    Venmans A, Lohle PNM, van Rooij WJ et al (2008) Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. AJNR Am J Neuroradiol 29:1983–1985.  https://doi.org/10.3174/ajnr.A1269 CrossRefGoogle Scholar
  16. 16.
    Kim YJ, Lee JW, Park KW et al (2009) Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology 251:250–259.  https://doi.org/10.1148/radiol.2511080854 CrossRefGoogle Scholar
  17. 17.
    Kim SY, Seo JB, Do K-H et al (2005) Cardiac perforation caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJR Am J Roentgenol 185:1245–1247.  https://doi.org/10.2214/AJR.04.1443
  18. 18.
    Schuerer S, Misfeld M, Schuler G, Mangner N (2015) Intracardiac cement embolization in a 65-year-old man four months after multilevel spine fusion. Eur Heart J 36:783.  https://doi.org/10.1093/eurheartj/ehu300 CrossRefGoogle Scholar
  19. 19.
    Dash A, Brinster DR (2011) Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Ann Thorac Surg 91:276–278.  https://doi.org/10.1016/j.athoracsur.2010.06.106 CrossRefGoogle Scholar
  20. 20.
    Llanos RA, Viana-Tejedor A, Abella HR, Fernandez-Avilés F (2013) Pulmonary and intracardiac cement embolism after a percutaneous vertebroplasty. Clin Res Cardiol 102:395–397.  https://doi.org/10.1007/s00392-013-0542-9 CrossRefGoogle Scholar
  21. 21.
    Hatzantonis C, Czyz M, Pyzik R, Boszczyk BM (2016) Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy. Eur Spine J.  https://doi.org/10.1007/s00586-016-4695-x
  22. 22.
    Audat ZA, Alfawareh MD, Darwish FT, Alomari AA (2016) Intracardiac leakage of cement during kyphoplasty and vertebroplasty: a case report. Am J Case Rep 17:326–330CrossRefGoogle Scholar
  23. 23.
    Mattis T, Knox M, Mammen L (2012) Intracardiac methylmethacrylate embolism resulting in right atrial wall perforation and pericarditis following percutaneous vertebroplasty. J Vasc Interv Radiol 23:719–720.  https://doi.org/10.1016/j.jvir.2011.12.027 CrossRefGoogle Scholar
  24. 24.
    Shridhar P, Chen Y, Khalil R et al (2016) A review of PMMA bone cement and intra-cardiac embolism. Materials (Basel) 9:821.  https://doi.org/10.3390/ma9100821
  25. 25.
    Righini M, Sekoranja L, Le Gal G et al (2006) Pulmonary cement embolism after vertebroplasty. Thromb Haemost 95:388–389CrossRefGoogle Scholar
  26. 26.
    Krueger A, Bliemel C, Zettl R, Ruchholtz S (2009) Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 18:1257–1265.  https://doi.org/10.1007/s00586-009-1073-y CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Nieuwenhuijse MJ, Van Erkel AR, Dijkstra PDS (2011) Cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: identification of risk factors. Spine J 11:839–848.  https://doi.org/10.1016/j.spinee.2011.07.027 CrossRefGoogle Scholar
  28. 28.
    Loeffel M, Ferguson SJ, Nolte L-P, Kowal JH (2008) Vertebroplasty: experimental characterization of polymethylmethacrylate bone cement spreading as a function of viscosity, bone porosity, and flow rate. Spine (Phila Pa 1976) 33:1352–1359.  https://doi.org/10.1097/BRS.0b013e3181732aa9
  29. 29.
    Bohner M, Gasser B, Baroud G, Heini P (2003) Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials 24:2721–2730CrossRefGoogle Scholar
  30. 30.
    Baroud G, Crookshank M, Bohner M (2006) High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine (Phila Pa 1976) 31:2562–2568.  https://doi.org/10.1097/01.brs.0000240695.58651.62
  31. 31.
    Meng B, Qian M, Xia S-X et al (2013) Biomechanical characteristics of cement/gelatin mixture for prevention of cement leakage in vertebral augmentation. Eur Spine J 22:2249–2255.  https://doi.org/10.1007/s00586-013-2886-2 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Potet J, Weber-Donat G, Curis E et al (2013) Incidence of pulmonary cement embolism after real-time CT fluoroscopy-guided vertebroplasty. J Vasc Interv Radiol 24:1853–1860.  https://doi.org/10.1016/j.jvir.2013.05.048

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Sarah Fadili Hassani
    • 1
  • Evelyne Cormier
    • 1
  • Eimad Shotar
    • 1
    • 2
  • Mehdi Drir
    • 3
  • Jean-Philippe Spano
    • 2
    • 4
  • Laetitia Morardet
    • 5
  • Jean-Philippe Collet
    • 6
  • Jacques Chiras
    • 1
    • 2
  • Frédéric Clarençon
    • 1
    • 2
    Email author
  1. 1.Department of NeuroradiologyPitié-Salpêtrière Hospital, APHPParisFrance
  2. 2.Paris VI UniversityPierre et Marie CurieParisFrance
  3. 3.Department of AnesthesiologyPitié-Salpêtrière HospitalParisFrance
  4. 4.Department of OncolyPitié-Salpêtrière HospitalParisFrance
  5. 5.Department of RheumatologyPitié-Salpêtrière HospitalParisFrance
  6. 6.Department of CardiologyPitié-Salpêtrière HospitalParisFrance

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